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"APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS
L O CAT I O rr AtClr �SCt. '1/(�t�P s -oT-. . G
VILLAGE
,I N YA tJ bJ lS C EIS-F2V t l.tom ----
APPLICANT DATE * ..
S��UitAIIJ� �, IWC• �
ADDRESS FEE /
' TELEPHONE NO. `]71-jo� (Non-refundable
'ENGINEER
TELEPHONE N0.
E•:'.SCHEDULED
D11T
(Applicant' s signature
• ASSH ORt'S°bi�I'°� or No; ° ° . . . ° ° . . . . . ° . . . ° . . . . . . . . ° ° .° . . . . . . . ° . ° . '. . ° ° . o . . . . ,
',��/ SOIL LOG /
SUB-DIVISION NAIJE l$(„g VV00rS DATE
�--
E;ZPANS ION. AREA: YES ✓Np TIb1E
-- -_ ( y,0 G. ENGINEER:'R'
TOWN PLATER ✓PRIVATE WELL INA Al.y BOARD OF HEAL?
• — _!�MSSC�LC.�` EXCAVATOR
SKETCH: (street name, etc. ,dimensions',of lot, exact location of test holes
percolation . tests, locate wetlands in and
proximity to test holes)
NOTES:
(OIL-
14,^�Z
PERCOLATION RATE:
TEST HOLE NO: ELEVATION:
1 MAA TEST HOLE NO• ELEVATION:
2
4 2� 3
All 6M
6 6
7 7
8
g 9
10
10 - ..
12
13 12
14 . 13
15 14
.16 • ,
15
SUITABLE *FOR_ SUB-SURFACE SEWAGE: . LEACHINGIFIELD
LEACHING TREN:CHES_r RING PITS`_
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
r10TE: ENG•INE2RING PLANS 14UST SHOW NU14BER• ASSIGNED .ON PERC TEST APPLICATION
ORIGINAL': 'COMPLETED IN ENT RE p
ANn COPY: RETAINED BY APPLICANT RNED TO BOARD OF HEALTH'